Navigation systems and platforms in natural orifice translumenal endoscopic surgery (NOTES)

Abstract

Introduction: The latest evolution in minimally invasive surgery is to avoid skin incisions by using natural orifices, called natural orifice translumenal endoscopic surgery (NOTES). However, to safely and efficiently perform NOTES, the requirements of the operating platform used need to be modified from the conventional endoscope. The aim of this paper is to systematically review specialised operating platforms used or in development for NOTES procedures.

Methods: A review of the literature was conducted using Ovid EMBASE, Ovid MEDLINE, ISI Current Contents Connect and PubMed, a search tool of the National Library of Medicine and the national institute of Health, until the 1st of December 2008. Data was extracted to specifically characterise the available platforms, their availability, advantageous characteristics and potential disadvantages.

Results: There were 9 studies included in this review describing 6 different navigation platforms and 3 robotic systems for NOTES. Based on this analysis, it is our opinion that although the described surgical systems and navigation platforms possess some attractive characteristics, such as maneuverability, stability, enhanced optics, and the ability to provide triangulation and insufflation with proper suction/irrigation maintenance, there does not appear to be one platform which is clearly superior to others.

Conclusion: Current instruments are not suited for effective surgery in a NOTES environment. There are several important requirements for NOTES platform: 1) to provide safe access to the peritoneal cavity; 2) to provide a stable channel for instrumentation passageway and safe navigation, 3) to provide good visualization and illumination, thereby decreasing disorientation, 4) to maintain proper insufflation and suction/irrigation, and 5) to provide maneuverability and triangulation of the instruments. Effective collaborations between clinicians, engineering departments and industry are essential to maximise and expedite the innovative process in producing an optimal NOTES platform.